THE EFFICIENT OPHTHALMOLOGIST

Patient compliance: Whose problem is it really anyway?

In a doctor-patient partnership, compliance is a shared responsibility.

By Steven M. Silverstein, MD, FACS

In every medical specialty, patient noncompliance with medication regimens remains a considerable concern. It frustrates physicians greatly. After all, why won’t the patient simply do as we recommend or prescribe in their best interest?

It costs the provider time and the health-care system dollars, and, worst of all, the patient risks unnecessary morbidity or mortality. It is understandable after years of pleading with patients, to finally resign ourselves to the notion of “Oh well. It is their eye. It is their health. We cannot force patients to behave in their own best interest.”

DEFINING NONCOMPLIANCE

For ophthalmologists, noncompliance is defined as the patient either being unable or unwilling to use a given medication as prescribed, or refusing a diagnostic test or medical procedure to address an acute or chronic subjective symptom or clinical sign. Primary-care physicians have an even greater challenge; noncompliance reveals itself as the patient’s unwillingness to change certain behaviors destructive to health — such as smoking, substance abuse and poor diet.

Sometimes compliance itself is difficult. For example, the burden of aggressive treatment regimens such as antibiotics every hour or two, or regular anti-inflammatories, is considerable. Patients often start with good intentions, but become either distracted when they start feeling better or they get lazy. I admit there have been times when I started myself on a given regimen (oral antibiotic for a lingering URI) and became noncompliant with my own prescription!

Sometimes noncompliance comes in the form of denial: Glaucoma doesn’t hurt and the patient is typically asymptomatic. So patients think what’s the harm if they don’t follow their doctor’s instruction for administering their medications.

HABITS OF NONCOMPLIERS

Countless studies have defined the extent and prevalence of noncompliance. In one such study, utilizing early microchip technology in the 1980s, a processor recorded exactly when and on which day(s) a patient squeezed a drop of glaucoma medicine from the bottle.¹

Among its revelations, this study taught us that noncompliance was much more common than we suspected, especially when compared to patient diaries or direct examiner questioning, and that patients used their drops most accurately and consistently for the first few days following their appointment with the doctor, and for the two to three days before their next appointment.

ECONOMIC IMPLICATIONS

Indeed, this issue has tremendous economic implications. One of the common reasons patients give for noncompliance is the cost of medication, or co-pays for medicines or procedures. In addition, the economic impact is also seen on the payer side, as noncompliance early in the course of a disease may lead to more expensive or long-term procedures, such as glaucoma surgery or chronic therapy (multiple medications), which may have been avoided with reliable early intervention.

Seeking a solution, a company called SMRxT (New York) is conducting pilot programs with third-party payers to develop a pill bottle that reminds and tracks patient medication usage. If the patient is deemed noncompliant, the payer may opt out of paying for future use of the medication. A little too Big Brother? Perhaps, but in the end, patients could be the ultimate beneficiaries despite themselves.

CAN WE CHANGE BEHAVIORS?

Motivational interviewing has been a large and growing movement since William Miller and Stephen Rollnick introduced the concept in 1991.² This approach tackles the issues behind noncompliance, and allows us to a road map for physicians to help people help themselves.

More recently, Mr. Rollnick, Pip Mason and Christopher Butler, in their book Health Behavior Change, noted “Many encounters in health practice are not so simple, none more so than those in which symptoms or the threat of them are related to the lifestyle or behavior of the patient.” Further, they discuss the concept of “negotiation” R. J. Botelho first raised in 1992,³ as a way to resolve behavior change issues.

BE PROACTIVE WITH NONCOMPLIERS

So what can we do in our practices to reduce noncompliance and serve as the patient’s strongest health advocate and partner? EHR has given us the ability to quickly show patients the results of their tests, such as the multi-view for visual fields, which, on one page, demonstrates disease progression in real time, including the just-completed test.

I have many patients back down from their refusal to add another medication or remain on a branded product rather than switch to a generic I do not trust in a given class based solely on a three-minute review of their visual fields. In other words, seeing the consequences of proper or improper behavior is powerful, similar to the studies that have demonstrated that showing teenagers a black lung from the autopsy of a deceased smoker may reduce the incidence of cigarette use.

Next, actively engage family members or loved ones when reviewing tests and discussing compliance, enlisting them as either a caregiver or at least a compliance officer.

Ask patients to identify the barriers to their own good compliance, and help develop a strategy for success. If it’s a cost issue, find a less expensive alternative; if a memory issue, suggest a watch or small timer with an alarm.

Finally, make your patients aware how much you care about their well-being and help them understand that any unnecessary loss of visual function would make you very sad. It is a partnership. Compliance I would argue, is a shared responsibility. OM

Steven M. Silverstein, MD, FACS, is a cornea-trained comprehensive ophthalmologist in practice at Silverstein Eye Centers in Kansas City, Mo. He invites comments. His e-mail is ssilverstein@silversteineyecenters.com.

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